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Surveillance
Dr. Amna Rehana Siddiqui
Associate Professor
Department of Family & Community Medicine
College of Medicine King Saud University
COMM 311
Objectives: To
• Define surveillance for infectious diseases
• Know the objectives and uses of
surveillance system
• Recognize the elements of surveillance
system
• Be able to assist in establishing a
surveillance system
What is surveillance ?
• Ongoing process that is used to collect,
manage, analyze, interpret, and report this
information for action is called surveillance.
• e.g. surveillance for neonatal mortality in
Neonatal Intensive Care Unit and unusual
….sepsis….change in antibiotic use
Examples
• For diseases:
– Communicable diseases: influenza,
HIV/AIDS, sexually-transmitted infections
– For disease outbreaks: e.g. food poisoning,
cholera
– Non-communicable diseases: lead
poisoning, cancer, hypertension, diabetes
– Risk factors: tobacco use, physical
exercise
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Examples
• For emergencies: bioterrorism,
chemical, radiation, natural disasters
• For hospitals: e.g. nosocomial
infections.
• In the industry: for occupational
disorders, injuries, disability pensions
• In the military: for diseases of the
recruits
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Surveillance
• Continuous collection, collation and analyses
of data with or without subsequent action
• Clusters of disease in time and space
• Sudden changes in incidence ~ epidemics
• Sensitivity: detect an epidemic situation
• Specificity ~ correctness of data
• Sentinel surveillance systems; collection of
samples from selected / sampled clinics e.g.
influenza vaccine development each year
Describing Surveillance
• Surveillance systems are networks of
people and activities to keep this process
• Functions at local to international levels.
• Populations under surveillance are defined
by the information needs of prevention or
control programs.
Describing Surveillance
• New public health problems e.g. new
infectious strains / diseases; rapid
implementation of surveillance is effective
in early response.
• Over time, it is used to identify changes in
the nature or extent of health problems
and the effectiveness of public health
interventions.
Describing Surveillance
• Surveillance systems are generally called
on to provide descriptive information
regarding when and where health
problems are occurring and who is
affected—the basic epidemiologic
parameters of time, place, and person.
Objectives of Surveillance
• Descriptive epidemiology of health
problems e.g. measles vaccine doses
• Detection of outbreaks / lab based / else
• Program planning /intervention /evaluation
• Links to services
• Links to research
• Links to Education and Policy
• Monitoring incidence and prevalence
Steps in Surveillance Analysis
• Data quality
• Descriptive analysis
– Time
– Place
– Persons
• Generate hypothesis
• Test hypothesis
Descriptive Analysis of Time
• Graphical analysis
• Requires aggregation on appropriate time unit
• Choice of the time variable
– Date of onset
– Date of notification
• To describe trend, seasonality, and residuals
• Use of rates when denominator changes over
time
Descriptive Analysis of Time
Graphical analysis
25
Number of cases
20
15
10
5
0
37
1996
50
11
24
37
1997
Weeks
50
11
24
37
1998
Burden of diseases
• Reporting only confirmed cases may not
reflect true status resulting in ineffective
control
• Only severe cases are reported
• Under reporting may lead to high case
fatality rates; resource utilization affected
Approaches to Surveillance
•
•
•
•
•
•
•
•
•
Active versus passive
Notifiable diseases
Laboratory based
Registries
Surveys
Information systems
Record linkage
Combination of surveillance methods
Volunteers
Elements of Surveillance system
• Case definition : (possible, probable, confirmed)
• Population under surveillance (hospitals, prisons,
schools, factories, national, international)
• Cycle of surveillance (recognizing health event,
notifying it, information transfer, networks, action)
• Confidentiality (e.g. HIV+ve children in schools)
• Ethics (when research is involved)
• Laws (as a service component governed by law in
USA; e.g. disease notification)
Case Definition
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•
•
•
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Standard set of criteria
Clinical and lab
Allows for comparison
Sensitive vs. Specific
Refer to standard definitions stated by
WHO and CDC
Case Definition Gradient
Low Specificity
High Specificity
Suspected
Probable
Confirmed
Case Definition
• Smallpox
– Clinical Description
• An illness with acute onset of fever >101 °F followed by a rash
characterized by vesicles or firm pustules in the same stage of
development without other apparent cause.
– Laboratory Criteria for Confirmation
• Isolation of smallpox (variola) virus from a clinical specimen, or
• Polymerase chain reaction (PCR) identification of variola DNA
in a clinical specimen, or
• Negative stain electron microscopy (EM) identification of variola
virus in a clinical specimen (Level D laboratory or approved
Level C laboratory)
•
Probable Case of Smallpox
A case that meets the clinical case
definition that is not laboratory
confirmed but has an epidemiological
link to another confirmed or probable
case.
• Confirmed Case of Smallpox
A case of smallpox that is laboratory
confirmed.
Working Case Definition
• Smallpox Outbreak
- Anyone who meets original case definition
- Anyone with fever (>101 °F ) or rash who
was in a confirmed exposed area during the
Bioterrorism (BT) event or came in contact
with a confirmed or probable case should be
considered a case. (until confirmed; if not
confirmed; will be under observation and could be
classified as “case”; and others as “confirmed
cases”)
Disease notification
•
•
•
•
Physicians
Laboratories
Hospitals
Countries to CDC , WHO
Fig. 2
Cholera,
reported
cases
and case
fatality
rates,
per
Continent
Disease notification
• Instituted for rapid application of
prevention measure
• List of diseases vary by country
• Notification goes by mail /fax
• Information on form includes dx, date of
onset, age, sex, and place of residence;
may contain Sx, Rx given, and precautions
Validity of notification data
•
•
•
•
Seeking of medical care is not constant
Distance to the nearest hospital
Cost and distance to travel
Media reports will increase the # of people
reporting to the hospital e.g. dengue fever
• Public awareness will increase the
incidence
Data Quality Issues
• Missing values
• Attraction to round figures
• Data entry errors
• Bias related to lack of representativity
– Cases more severe
– Urban > rural
– Source not represented
(private sector, GPs)
Timeliness of disease notification
1.
2.
3.
4.
5.
6.
7.
8.
Health event occurs
Identified by health care system
Reported to local health authority
Verification/investigation by PHS
Health event reported to other systems
Analyses of health data
Dissemination of surveillance finding
Actions based on surveillance findings
Early warning system
• Major threats to the population; 0-4 & 5 or more
years of age, have been identified.
• Severe malnutrition, injuries, acute watery
diarrhoea, bloody diarrhoea, acute flaccid
paralysis, acute respiratory infections, neonatal
tetanus, malaria, suspected measles, suspected
meningitis, acute jaundice syndrome and acute
FUO
• A threshold for each is defined; unusual pattern
or occurrence will triggers investigations and
responses.
Summary: Surveillance data
• Monitors long term trends
• To make comparisons
• Analyze costs and benefits of preventive
measures
• Demands on quality of data
• To promote the best use of public health
resources, all public health surveillance
systems should be evaluated periodically
•
References
• Teutsch SM, Churchill RE. Principles and practice of
public health surveillance. Oxford: Oxford university
press, 2000
• Modern Epidemiology 2008; 3rd Edition Kenneth J
Rothman. Chapter 22 Surveillance
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